Letter to the Editor

Sixty Years of Free Medical Care

The following letter was submitted to ASCO News & Forum in response to the U.S. presidential election and the changes in health care that may result during the new administration. The views and opinions expressed are those of the authors alone and do not necessarily reflect the views or positions of the Editor or of the American Society of Clinical Oncology.

In the United Kingdom (U.K.) we watch with interest as President Obama works to expand health care coverage while reducing costs. Last year our nation marked the 60th anniversary of the creation of the National Health Service (NHS ). Its purpose was to guarantee people of the U.K. any type of health care they needed at no immediate cost, irrespective of the patient’s income.

Monies available to U.K. health care are predetermined by Her Majesty’s Treasury. The Department of Health in turn disburses its budget to the bodies that operate the NHS . The NHS relies on general practitioners (GP s) to contain costs. GP s are proud of their roles as gatekeepers. Referral of patients is reserved for situations in which a specialist’s diagnostic expertise or more than the most minor of surgical procedures is required. GP s are contracted to Primary Care Trusts, which control the bulk of NHS planning. Their referral management offices vet all specialist referrals except for referrals made when GP s suspect cancer.

Revised criteria for suspicion of cancer were published in 2005.¹ Patients with obvious symptoms, for example, postmenopausal bleeding, will have their first specialist appointment within two weeks. GP s have successfully administered the longest established screening service for pathology of the uterine cervix. As a result, the U.K.’s performance in the diagnosis and treatment of cervical and endometrial cancers is quite good. It is not good for ovarian cancer where the presenting symptoms are ambiguous and capacity for their investigation is limited.

Patients’ socioeconomic status has a great bearing on health outcomes. Access to medical care is free at the point of use; it does not depend on wealth. Wealthier patients still receive diagnoses and treatments for cancer much more effectively than other groups. If the U.K. is to improve cancer survival, it must address the recruitment of primary care staff in deprived areas so that cancer in underserved patients can be diagnosed and treated in a timely manner.

NHS doctors’ gatekeeping also diminishes the perception of demand. When I started work in a District General Hospital (DGH ) two decades ago, the purpose of my service was questioned. The visiting radiotherapist and oncologist said that to spend one day per week at the hospital was “sufficient for the present rate of referrals.” Unfortunately, the gatekeeping attitude required of all services made this perfectly true. As medical oncology and clinical oncology (clinical oncologists practice radiotherapy) services have increased in the last few years, more needs have been recognized.

As the young NHS streamlined its organization, three specific services were centralized. Neurosurgery was already centralized. Regional radiotherapy centers were established and smaller units were closed. Thoracic surgery was restricted to a limited number of hospitals. The distance between the patient’s residence and the thoracic surgery or radiotherapy facility affects one’s likelihood of receiving such interventions for lung cancer.² Yet these facilities have insufficient capacity to cope with their current patient loads.

While specialist services were centralized, the many small hospitals that the NHS absorbed were condensed into a smaller number of DGH s. The hospital where I work opened in 1970. In its 650 beds and outpatient facilities, it then provided all the internal medicine, general surgery, and obstetrics and gynecology services for approximately 175,000 people. Over time, the number of beds available to the population has shrunk with the closure of the outlying hospitals that provided longer-term and convalescence services. Currently, beds at the main hospital are being closed, but the number of specialists is increasing. The hospital now serves approximately 210,000 people and functions in a very multidisciplinary manner.

Current thinking at the NHS requires more specialized services to be provided in a few large centers with distribution of other services to community facilities based around GP s, not specialists. Gatekeeping is inherent in this system to match demand for centralized specialized services to capacity.

DGH s fit neither the commitment to locate more services close to home nor the pledge to centralize specialist services. Recent cancer planning strategies envision satellite clinics delivering chemotherapy close to, or within, patients’ homes, while doctors who prescribe it are based in the academic hospitals some distance away, perhaps establishing visiting clinics in DGH s. Having a medical oncology team based in a DGH is still very unusual in the NHS , but the idea is now finding favor.

Medicare data from U.S.-based research showed that outcomes for ovarian cancer surgery are slightly superior in the hospitals that were designated as “large.”³ Comparable data for NHS DGH s show that their workloads also would categorize the majority of them as large.⁴

For economically challenged parts of society, financial barriers to treatment are absolute. Few within the U.K. doubt that the “free at the point of need” NHS is the best way to overcome these obstacles. Such a service must be funded sufficiently to have the necessary capacity or, as the NHS illustrates, its aims will be defeated. Its facilities must be distributed widely to facilitate access; the DGH is a good starting point. If the Treasury balks at the cost of this, I see no reason to discourage wealthy patients from funding medical care privately, but the extra benefit they gain must be similar to the benefit of flying first class. The aircraft takes off and lands at exactly the same time but the circumstances in which one travels are merely more comfortable than economy class. So in cancer care, the quality of the medicine must be the same for all, but luxuries may differ.

—S. Michael Crawford, MD, FRCP
Consultant Medical Oncologist
Airedale General Hospital
United Kingdom

References

1.  National Institute for Clinical Excellence. Clinical Guideline 27, Referral guidelines for suspected cancer. London, NI CE 2005.
2.  Jones AP , Haynes R, Sauerzapf V, et al. Travel time to hospital and treatment for breast, colon, rectum, lung, ovary and prostate cancer. Eur J Cancer. 2008;44:992-9.
3.  Schrag D, Earle C, Xu F, et al. Associations between hospital and surgeon procedure volumes and patient outcomes after ovarian cancer resection. Natl Cancer Inst. 2006;98:163-71.
4.   Cancer treatment policies and their effects on survival – ovary. Key Sites Study 8. Northern & Yorkshire Cancer Registry and Information Service, Leeds, 2002. http://www.nycris.org.uk.

RESPONSE: Reforming Cancer Care: What Can We Learn from the United Kingdom?

As the largest organization representing U.S.-based oncologists, AS CO is vitally interested in promoting changes in the health system that support the goals of ensuring equal access to high-quality cost-effective cancer care for all patients. It is a matter of record that the current health care system in the United States is more costly than those of most major industrialized nations, and suffers from great inequities in access to care. Juxtaposed against these problems is the reality that U.S. health care is second to none in delivering highly technical care for diseases such as cancer. The problem we face is how to distribute the proper care to the appropriate patient in a way that is equitable, economically sound, and uniform in quality.

Dr. Crawford, in his essay “Sixty Years of Free Medical Care,” cites the obvious and welcome achievement of the U.K. National Health Service, which is universal availability of health care, independent of an individual’s income. Not surprisingly, he observes that the reliance on primary care physicians as gatekeepers is at the same time one of the great strengths of the program and one of its weaknesses. There is little doubt that this system has facilitated broad access to care and has done so with far more limited use of specialists than is the case in the United States. It appears that cancer prevention strategies that are of proven worth are widely disseminated, and are to be admired.

However, the regionalization of specialized services in the United Kingdom has in some instances the effect of limiting access to those services by reason of geographical misdistribution. For example, Dr. Crawford asserts that not all patients with lung cancer can get to the specialized regional centers for radiation therapy or thoracic surgery. Furthermore, these regional facilities are of insufficient size, so that over time they have become overloaded and cannot effectively meet the demand. He argues for a broader distribution of cancer care services, both in District General Hospitals (DGH ) and in satellite clinics. The latter are apparently slow in coming. There is much for us to learn from this.

The evolution of the U.S. health system has led to far less reliance on primary care physicians (PCPs) and far more use of specialists, leading to escalating costs and misdistribution of resources. This is almost the opposite of the scenario described in the U.K. Where do we go from here? Clearly, for cancer care, the answer is not that fewer oncologists are needed; indeed, our aging population causes us to project the need for an enlarging labor force that must be broadly distributed throughout the nation. However, we are obligated to make changes in the system that provide for several

absolute goals. One is the oft-stated goal of AS CO that every patient with cancer must have ready access to state-of-theart cancer care regardless of the ability to pay. A second is that cancer care must be evidence-based, and reflect contemporary assessments of the best available therapies defined in terms of clinical benefit, quality of life, and cost. We have shied away from defining value in cancer care, but that luxury is no longer extant.

To achieve these aims, the system for cancer care will have to change. The oncology community represented by AS CO must collaborate with like-minded organizations, patient advocates, and the government to develop policies that assure optimal delivery of care in a clinical environment that supports high-quality providers. Incentives for all the stakeholders in cancer care must become better aligned. These include cancer clinicians, our patients, the pharmaceutical industry, and insurers. Instead of four occasionally overlapping circles, these critical elements must be forged into a well-coordinated series of interwoven components whose primary focus is the well-being of the patient.

—Lowell E. Schnipper, MD
Theodore and Evelyn Berenson Professor of Medicine
Harvard Medical School
Chief, Hematology/Oncology Division
Beth Israel Deaconess Medical Center